Pre-Travel Assessment Form - Countries

*First Name: *Last Name: *Birth Date: (dd/mm/yyyy)
*Occupation: Medicare No: (10 digit number) Medicare Reference No: (The 1 digit number to the left of your name)
*Departure Date: Open Calendar (dd/mm/yyyy) *Return Date: Open Calendar (dd/mm/yyyy)
I will be visiting the following countries:
 # Countries (in order of visit) Duration Cities Rural More Information
*1
 2
 3
 4
 5
More Countries:
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